The importance of infection control in patient care

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Lecture by:
Dr. Satti M. Saleh
Chief of Infectious Diseases Department
CBAHI SIT Member
Medical Director MGH

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The importance of infection control in patient care

  1. 1. THE IMPORTANCE OF INFECTION CONTROL IN PATIENT CARE Dr. Satti M. Saleh Chief of Infectious Diseases Department CBAHI SIT Member Medical Director MGH
  2. 2. PEARLS OF WISDOM QUALITY OF CARE IS AS IMPORTANT AS QUALITY OF TREATMENT
  3. 3. International Patient Safety Goals IPSG  IPSG.1 Identify Patients Correctly  IPSG.2 Improve Effective Communication  IPSG.3 Improve the Safety of High-Alert Medications  IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery  IPSG.5 Reduce the Risk of Health Care– Associated Infections  IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls
  4. 4. PATIENT SAFETY An Organisation with a memory 17/02/2014
  5. 5. THE PARADIGM OF STRUCTURE , PROCESS & OUTCOME  THE RELATIONSHIP BETWEEN STRUCTURE , PROCESS & OUTCOME IS A CAUSAL RELATIONSHIP “DONABEDIAN “ ARRANGEMENT OF PARTS OF CARE SYSTEM OR ELEMENT OF CARE STRUCTURE CLINICAL CARE DELIVERY ADMINISTRATIVE PROCESS LEADS TO LEADS TO REFERES TO RESULTS OF CARE (ADVERSE OR BENIFICIAL ) OUTCOME •CLINICAL •FUNCTIONA •PECEIVED
  6. 6. Infection Control Programme Structure 1) INFECTION CONTROL UNIT : Independent IPP's all patient care areas Infection control policy standard 2) CURRENT SCIENTIFIC KNOWLEDGE 3) ICP : FULL TIME 4) QUALIFIED PERSONNEL 5) IC MANUAL 6) CONTINUE EDUCATION.  Infection Control Personnel  Staff Orientation  Staff Continuous Education 7) IC COMMITTEE
  7. 7. GOAL FOR HOSPITAL INFECTION PREVENTION &CONTROL PROGRAMMS     PROTECT THE PATIENT . PROTECT HCWS VISITORS &OTHERS IN THE HEALTHCARE ENVIRONMENT ACCOMPLISH PREVIOUS GOALS ,WHEREVER POSSIBLE , IN A COST EFFECTIVE MANNER
  8. 8. Definition Of HCAI
  9. 9.   INFECTION OCCURRING DURING OR AS A RESULT OF HOSPITALIZATION WHICH THE PATIENT NEITHER HAVING NOR INCUBATING AT THE TIME OF ADMISSION.
  10. 10. Importance
  11. 11. INCREASE PROBLEMS DUE TO :1-ADVANCE TECHNOLOGY 2-OVERCROWDING 3-POOR RESOURCES 4- USES OF ANTIBIOTICS 5-INCREASE INVASIVE PROCEDURES 6-IMUNOSUPRESSION 7-SHORTAGE OF TRAINED STAFF
  12. 12. MISCONCEPTIONS ? 1-IC IS EXPENSIVE 2-DIFFICULT TO IMPLEMENT 3-NO RISK TO STAFF 4-BLOOD BORN PATHOGENS 5-SCREENING IN EMERGENCY 6-SCREEING IS COSTLY
  13. 13. Surveillance Program     CONTINUOUS OR PERIODIC. DIRECTED TO ALL INFECTIONS OR TARGETED SITES / DEVICES. ALL NEED TO BE SUPPLEMENTED BY MICROBIOLOGY LABORATORY BASED SYSTEMS. TECHNIQUES:  REVIEW ANTIBIOTIC RECORDS.  PATIENT / NURSING CARE RECORDS  MICROBIOLOGY RESULTS  AUGMENT BY AFTER ICU FOLLOW UP.  AUTOPSY REPORTS
  14. 14. Surveillance  INFECTION CONTROL PROGRAM CLOSELY MONITORS THE FOLLOWING: PATIENTS AT HIGH RISK OF INFECTION. PATIENTS WITH ALREADY ACQUIRED INFECTIONS. PERSONNEL/PATIENTS EXPOSED TO COMMUNICABLE DISEASES, CONTAMINATED EQUIPMENT, OR HAZARDOUS REAGENTS. PATIENTS IN CERTAIN AREAS OF THE HOSPITAL OR IN CERTAIN ROOMS. PATIENTS IN AMBULATORY SETTINGS: HOME OR LONG-TERM CARE FACILITIES.  SURVEILLANCE IS ALSO INVOLVED IN CLASSIFYING INFECTIONS ACCORDING TO PREVALENCE RATES AND MONITORING EMPLOYEE HEALTH INCLUDING SCREENING FOR DISEASES AND OFFERING IMMUNIZATIONS. Phlebotomy Handbook: Blood Collection Essentials, Seventh Edition Diana Garza • Kathleen Becan-McBride Pearson Education Copyright 2005
  15. 15. CHAIN OF INFECTION Organism Source Mode of Transmission Host
  16. 16. NEW ISOLATION PRECAUTIONS, 1996 ‘’ STANDARD’’ AND ‘’ TRANSMISSION – BASED PRECAUTIONS’’
  17. 17. A-ESSENTIAL STANDARD PRECAUTIONS 1- HAND HYGIENE. 2- PPE . 3- ASEPTIC TECHNIQUES 4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.
  18. 18. HAND HYGIENE . HAND HYGIENE IS THE SINGLE MOST IMPORTANT PRACTICE TO REDUCE THE TRANSMISSION OR INFECTIOUS AGENTS IN HEALTHCARE SETTINGS . . THE TERM “HAND HYGIENE” INCLUDES :  HAND WASHING WITH EITHER PLAIN OR ANTISEPTIC CONTAINING SOAP AND WATER .  USE OF ALCOHOL-BASED PRODUCTS ( GELS, RINSES, FOAMS) CONTAINING AN EMOLLIENT THAT DO NOT REQUIRE THE USE OF WATER.
  19. 19. RATIONALE TRANSIENT FLORA (Contaminating or non – colonizing)   Attached to the superficial layer of skin. Microbes isolated from skin not consistently present in majority of persons associated with HCAI . RESIDENT FLORA  Attached to deeper layer of the skin persistently isolated from skin of most persons (cons, diphtheriods )
  20. 20. TYPE OF HAND HYGIENE 1) 2) 3) 4) Intensity of contact . Degree of contamination . Susceptibility of patient to infection . Prove dure to be performed .
  21. 21. HAND HYGIENE  In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over hand washing with water and antimicrobial or plain soap because of their superior microbiocidal activity, reduced drying of the skin, and convenience.
  22. 22. HAND HYGIENE In observational studies of opportunities for hand washing in health care workers in U.S.A  The overall compliance was 40% (range 5 – 81%) .  Compliance was highest among nurses and lowest among physicians, in intensive care units, and when required intensity of care was greater . 
  23. 23. HAND WASHING STUDY IN RIYADH MEDICAL COMPLEX-GENERAL HOSPITAL Overall frequency of hand washing .  23.7% after patient contact .  6.7% before patient contact . 
  24. 24. HAND WASHING   - Health care infection control practices advisory committee (HICPAC) former recommendations Plain soap and water was recommended for routine hand washing. Antimicrobial soaps (e.g. : chlorhexidine) was recommended for : Patients under contact precautions . During instances of epidemic or hyperendemic spread of infections.
  25. 25. A-ESSENTIAL STANDARD PRECAUTIONS 1- HAND HYGIENE. 2-Personal Protective Equipment (PPE) . 3- ASEPTIC TECHNIQUES 4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.
  26. 26. What are Personal Protective Equipment (PPE)?  Items specified for protection of many parts of body (to reduce risks to the health and safety of HCWs, and to minimize risks of cross infection between patients, staff, visitors) e.g. gloves, masks, respirators, goggles, specialized clothing (aprons & gowns)
  27. 27. Common PPEs Gloves  Aprons and gowns  Face, mouth, nose, eye Protection  Foot protection  Head coverings 
  28. 28. Evidence shows hand washing prevents infections, but does PPE?  If health workers currently use PPE that doesn’t mean it is effective.  One role of Infection Control Staff is to assess the changing risks and practices. ◦ Stop practices that are ineffective, expensive. ◦ Help institute cost-effectiveness practices of proven efficacy.
  29. 29. Last reminder     Don’t assume current PPE use is effective Assess where and how employees are getting exposed to body fluids and harmful exposures. Assess how patients are getting disease from staff Select PPE that rationally protects patients and staff. Measure costs.
  30. 30. A-ESSENTIAL STANDARD PRECAUTIONS 1- HAND HYGIENE. 2- PPE 3- ASEPTIC TECHNIQUES 4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.
  31. 31. ASEPSIS (ASEPTIC TECHNIQUE) REFERS TO PRCEDURES PERFORMED UNDER STERILE CONDITION  DEFINED AS A SET OF SPECIFIC PRACTICES & PROCEDURES PERFORMED UNDER CAREFULLY CONTROLLED CONDITIONS WITH THE GOALOF MINIMIZING CONTAMINATION BY PATHOGENS   e.g.  DRAIN REMOVAL & CARE RESPIRATORY SUCTION
  32. 32. A-ESSENTIAL STANDARD PRECAUTIONS 1- HAND HYGIENE. 2- PPE 3- ASEPTICTECHNIQUES 4- REPROCESSING OFINSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.
  33. 33. REPROCESSING OF REUSABLE INSTRUMENTS CLEANED & MAINTAINED ACCORDING TO MANIFACTURER INSTRUCTIONS  SINGLE USE DEVICES DISCARDED AFTER ONE PATIENT  DEVICES FLOW FROM HIGH CONTAMINATION TO STERILE AREA  DEVICES STORED IN A MANNER TO PROTECT FROM DAMAGE 
  34. 34. A-ESSENTIAL STANDARD PRECAUTIONS 1- HAND HYGIENE. 2- PPE . 3- ASEPTICTECHNIQUES 4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.
  35. 35. 5- ENVIROMENTAL CLEANING SURFACE CLEANED & DISINFECTED  CLEANERS & DISINFECTANTS ARE USED IN ACCORDANCE WITH MANIFACTIORER INSTRUCTIONS. 
  36. 36. A-ESSENTIAL STANDARD PRECAUTIONS 1234- HAND HYGIENE. PPE . ASEPTIC TECHNIQUES REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.
  37. 37. Factors which increase risk of infection        Deep injury. Visible blood on the device. High viral titer. Artery or vein device. Combined factors. Un-immunized against hepatitis B. No post exposure prophylaxis with Zidovidine (prophylaxis decrease risk by 80%). 2/17/2014 39
  38. 38. Risk of Transmission of Blood born Infection Occupational Exposure Hepatitis B Virus Risk of Transmission 2-40% Hepatitis C Virus 2.7-10% HIV 0.3% (1 in 300 chance of infection) 2/17/2014 40
  39. 39. Hazards of Needle stick injuries Hepatitis B and C.  HIV.  Brucellosis.  Malaria.  S. aureus and S. pyogenes.  Toxoplasmosis.  Tuberculosis.  2/17/2014 41
  40. 40. How can needle stick injuries be prevented Employee training.  Recommended guidelines.  Safe recapping procedures.  Effective disposal systems.  Surveillance programs.  Improved equipment design.  2/17/2014 42
  41. 41. B-Transmission-Based Precautions  Three categories of Transmissionbased Precautions :  Contact Precautions .  Droplet Precautions .  Airborne Precautions .
  42. 42. Contact transmission      Examples of organisms spread by contact: Multi-drug-resistant organisms in the gastrointestinal tract, sputum, or wounds (MRSA, MDR Gram –ve, VRE). Clostridium difficile. Herpes simplex virus (mucocutaneous). Scabies.
  43. 43. Contact precautions . Wash hands with antimicrobial soap before leaving the patient's room . . Minimize risk or environmental contamination during patient transport (e.g. patient can be placed in a gown ). . Patient’s care devices ( e.g. thermometer , BP cuffs , stethoscopes ) should be dedicated to use for a single patient if possible , otherwise, they should be rigorously cleansed and disinfected before use for other patients .
  44. 44. Contact precautions . Private room preferred; cohorting allowed if necessary . . The door of the room may remain open . . Gloves : - upon entering room . - change gloves after contact with contaminated secretions . - should be removed before leaving the room . . Gown: - if clothing may come into contact with the patient or environmental surfaces . - should be removed before leaving the room .
  45. 45. DROPLET TRANSMISSION  Respiratory droplets are large particles (>5 micron) expelled during :- Coughing . - Sneezing . - Talking. - During procedures such as suctioning and bronchoscope .   Droplets travel < 1,5 meter from the source patient . Example : • Neisseria meningitides . • Haemophilus influenza type b ( invasive ) . • Streptococcus pyogenes (group A Streptococcus) . • Mycoplasma pneumonia .
  46. 46. DROPLET PRECAUTIONS Private room preferred; cohorting allowed if necessary.  Special air handling and ventilation are unnecessary .  The door of the room may remain open .  Wear a mask when within 1 meter of the patient .  Mask the patient during transport . 
  47. 47. AIRBORNE TRANSMISSION   - - Airborne spreads upon aerosolization of small particles (=< 5 micron) of the infectious agent that can then travel over long distances through the air . Most common nosocomial pathogens transmitted by this route : Mycobacterium tuberculosis . Varicella-zoster virus (chickenpox) . Measles . Smallpox. ? SARS .
  48. 48. AIRBORNE PRECAUTIONS Place the patient in a negative pressure room with at least 6 – 12 air exchanges per hour .  Room exhaust must be appropriately discharged outdoors or passed through a HEPA ( high – efficiency particulate aerator ) filter before recirculation within the hospital .  The door of the room should be kept closed . 
  49. 49. Precautions Needed for Cases     Condition Pulmonary TB Negative Chicken Pox M-meningitis HIV Type S+A S+A S+D S Duration Till sputum Till rash crusted 24 Hrs Duration of stay Clinical Syndromes: Empiric precautions as per clinical presentation
  50. 50. COMMUNICABLE DISEASE
  51. 51.  Staff awareness  Measures toward patient's diagnosis, isolation disinfection etc.  Notification ◦ Class I, Class II
  52. 52. EMPLOYEE HEALTH
  53. 53.      Staff health clinic Physical examination Screening Vaccination Post exposure management ◦ *Blood, body fluids ◦ *Needle stick injury ◦ *Vaccine  -Staff accommodation  Vaccine preventable disease
  54. 54. SUPPORT SERVICES
  55. 55. a) CSSD b) House Keeping c) Mortuary & Postmortem Written policy disinfection & cleaning morgue temperature (2-8) logged daily d) Kitchen Environment & function Food container Food protection PPE Staff health & screening Written policy e)Laundry Linen management Laundry structure & function f)Haemodialysis Staff knowledge -PPE Standard precaution Structure Patient Medical Records (Screen Vaccination) Staff Medical Record -Haemodialysis water dialysate Water treatment -Written policy g) Operating Room Structure Traffic Control Pressure gradient & air cycle Cleaning Written policy
  56. 56. STERILIZATION
  57. 57. STERILIZATION OF REUSABLE INSTRUMENTS &DEVICES STERILIZATION PROCESS OF ELIMENATING (REMOVING)OR KILING MICROBIAL ORGANISMS PRESENTING ON THE SURFACE OR IN FLUID OR MEDIA  METHODS: ◦ ◦ ◦ ◦ ◦ HEAT IRRADIATION CHEMICAL HIGH PRESSURE RADIATION
  58. 58. DISINFECTION THE PROCESS OR ACT OF DISTROYING PATHOGENIC MICROORGANISMS OR MAKING THEM INERT (SOME CERTAIN BACTERIA SPORES MAY SURVIVE)  COULD BE CHEMICAL OR BY HEAT 
  59. 59. HIGH LEVEL DISINFECTION OF REUSABLE DEVICES
  60. 60. CLEANING REMOVAL OF VISIBLE SOIL FROM OBJECT & SURFACES  IT’S A FORM OF DECONTAMINATION 
  61. 61. OUTBREAK INVESTIGATION  OUTBREAKS ARE RECOGNIZED BY:◦ ◦ ◦ ◦ PRACTITIONER PATIENT &PATIENT FAMILY PUBLIC HEALTH SURVEILLANCE LOCAL DATD-MEDIA
  62. 62. OUTBREAK INVESTIGATION  REASONS TO INVESTIGATE :◦ ◦ ◦ ◦ PREVENT ADDITIONAL CASES PREVENT FUTURE CASES OUTBREAK LEARN ABOUT NEW DISEASES LEARN SOMETHING NEW ABOUT OLD DISEASES ◦ REASSURE THE PUBLIC ◦ ECONOMIC &SOCIAL REASONS
  63. 63. OUTBREAK INVESTIGATION  CONDUCTING AN OUTBREAK INVESTIGATION:- ◦ CASE INVESTIGATION ◦ CAUSE INVESTIGATION ◦ CONTROL MEASURES SHOULD BE DONE EARLY ◦ CONDUCT ANALYTIC STUDY IF NECESSARY ◦ CONCLUSIONS ◦ CONTINUE SURVEILLANCE ◦ COMMUNICATE FINDINGS eg. EPIDEMIOLOGICAL,CLINICAL,FORENSIC INVESTIGATION

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